The McKenzie Method

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The McKenzie Method

• An Overview
• Mechanical Diagnosis Therapy of the Spine
• A Dynamic System of Examination, Diagnosis,
  Intervention and Prevention

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Who is Robin McKenzie?
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History MDT

• Robin McKenzie
• Physiotherapist from New Zealand
• Dr. Cyriax
• strong influence on McKenzie's initial training
• considered the framework for MDT
• Clinical experience
• Mr. Smith 1956 2 weeks of radicular sx then
  serendipitous surprise
• Exploration of End Of Range - some improved,
  while others worsened

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History - cont

• Over next 20 years developed approach
• Began teaching approach 1977 Rancho Los Amigos
• McKenzie Institute formed in 1982
• 26 branches around the world

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Epidemiology

• 50-80 population experience back pain
• Peak prevalence 40-50 years of age and tapers
  after that
• Csp -Women tend to be affected more men
• Lsp Men tend to more affected than women
• First episodes of sx start in the 20s w/
  recurrency rates between 39-71
• Majority (80-90) of low back disorders occur at
  the L4/5 and/or L5/S1
• Most cervical disorders are found in the lower
  region with 41 occurring at the C5/6 level and
  33 at the C6/7 level
• When the nerve root is affected, 36.1 involve
  the C6 root (C5-6 level), 34.6 C7 (C6-7 level)
  and 25.2 C8 (C7-T1 level)

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Quebec Task Force Reports

• Spine 1987 Comprehensive Scientific,
  Multi-disciplinary Investigation
• Most spinal disorders are non-specific
• Classify by pain patterns

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Spitzer WO. Scientific approach to the assessment
and management of activity-related spinal
disorders A mono-graph for clinicians. Report of
the Quebec Task Force on Spinal Disorders. Spine
198712(7 Suppl)1-59.
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BIOMECHANICS
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Spinal Motion Segment

• Basic functioning unit of the spine
• Vertebra
• Intervertebral discs
• Annulus fibrosus
• Functions to retain nucleus
• Weakest posterolaterally
• Nucleus pulposa
• connecting ligamentous and soft tissue
  structures.
• Analysis of segment to
• Load
• Position
• Movement

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Conceptual Framework

• DISC MODEL

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Conceptual Model - Flexion

• Zygapophyseal joint surfaces distract
• inferior articular processes of the superior
  vertebra glide up and forward upon the superior
  articular surfaces of the vertebra below.
• Anterior loading of the intervertebral disc
  occurs with compression of the anterior portion,
  with relaxation and bulging of the outer anterior
  annular wall.
• The posterior annular wall is stretched and
  pulled taut.
• The nucleus distorts posteriorly.
• The vertebral canal lengthens, stretching the
  cord, dura and root filaments and opening the
  intervertebral foramina.

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Conceptual Model - Extension

• Inferior articular processes of the vertebra
  above glides down and backward on the superior
  articular surfaces of the vertebra below.
• Posterior loading of the intervertebral disc
  occurs with distraction of the anterior portion
  of the annulus, which is stretched and pulled
  taut.
• The posterior annular wall is relaxed and there
  is posterior bulging of the outer, posterior
  annular wall.
• The nucleus distorts anteriorly.
• The vertebral canal shortens, which relaxes the
  cord, dura and root filaments, and reduces the
  size of the intervertebral foramina.

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Literature

• Donelson R, Aprill C, Medcalf R, Grant W. A
  prospective study of centralization of lumbar and
  referred pain. A predictor of symptomatic discs
  and annular competence. Spine 22(10)1115-22,
  1997.

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• 63 subjects sent for PRE SURGICAL Discogram w/
  Gadolinium for confirmation of disc pre surgical
  diagnosis.

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• PTs trained in MDT, did mechanical evaluation.
  Therapist asked to predict
• Is the pain discogenic?
• If discogenic then what level?
• If discogenic then was nucleus contained?
• Predict what the disc fissure pattern would look
  like.
• The patients then got the discogram in flexion
  and extension.

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• Comparisons were made between the findings of the
  Discography and those predicted by the therapist.

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• Predicted vs Actual Discogram Results
• Discogenic?
• Agreement 83.3
• Level?
• Agreement 93
• Nucleus contained or non contained?
• Agreement 85.5
• Fissure Pattern?
• Agreement rated good/excellent

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Conclusion

• Dynamic disc injection outcomes are reliably
  predictable w/ MDT exam and the dynamic internal
  disc model
• This strongly supports a mechanical cause
  effect relationship between IVD dynamics and the
  symptom response patterns of centralization
• MDT exam appears to be a dynamic, non-invasive
  functional evaluation of symptomatic disc
  pathology

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TISSUE BASEDPAINMECHANISM
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• Nociception stimulation of receptors which
  provide feedback for pain
• Mechanical application of forces that contain
  the receptors is sufficient to irritate the free
  nerve endings (pressure, distraction, distension,
  abrasion, contusion, laceration)
• Chemical/Thermal - chemical irritation when
  concentration of chemical substances is
  sufficient to irritate free nerve endings.
• It is essential to identify the type of pain
  (chemical or mechanical) because this will
  establish the tissue state and the subsequent
  treatment selection

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Clinical Management

• Goal
• Relieve Pain
• Restore Function
• Prevent reoccurrence

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Classification

• Pain of spinal origin can be classified into 3
  syndromes.
• Posture Syndrome
• Dysfunction Syndrome
• Derangement Syndrome

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Posture Syndrome
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Posture Syndrome

• End range stress on normal structures
• Mechanical deformation due to prolonged stress
  eventually produces pain

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Dysfunction Syndrome
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Dysfunction Syndrome

• End range stress of adaptively shortened
  structures
• Mechanical deformation immediately produces pain
  at end of range
• May be discogenic, zygapophyseal, ligamentous,
  muscular, apeneurosis, etc

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Derangement Syndrome
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Derangement Syndrome

• Anatomical disruption and/or displacement of
  structures
• The structures increased mechanical deformation
  immediately or eventually produce pain

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Definition of Terms

• Centralization
• Describes the phenomenon in which limb pain
  emanating from the spine is progressively
  abolished in a distal to proximal direction in
  response to therapeutic loading strategies , with
  each progressive symptom change being retained
  over time. If back pain only is present this is
  reduced and then abolished.
• Peripheralization
• Describes the phenomenon by which pain emanating
  from the spine spreads distally into or further
  into the limb as a result loading strategies. If
  pain is produced in the limb, spreads distally or
  increases distally and remains worse the loading
  strategy should be avoided.

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Centralization/Periperalization - cont
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Defn - cont

• Lateral shift (right)
• A lateral shift exists when the vertebra above
  has laterally flexed to one side in relation to
  the vertebra below, carrying the trunk with it.
  (The upper trunk and shoulders are displaced to
  the right.)
• Contralateral and ipsilateral shift
• A contralateral shift exists when the patient's
  symptoms are on one side and the shift is in the
  opposite direction. For instance, left back pain,
  with / without thigh / leg pain, and upper trunk
  and shoulders displaced to the right.

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Lateral Shift
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Defn - cont

• Criteria for Relevant lateral shift (structural
  vs habitual)
• Upper body is visibly and unmistakably shifted to
  one side
• Onset of shift occurred with back pain
• Patient is unable to correct shift voluntarily
• If patient is able to correct shift they cannot
  maintain correction
• Correction affects intensity of symptoms
• Correction causes centralization or worsening of
  peripheral symptoms

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Defn - cont

• Symptomatic responses
• The changes in the patient symptoms that are
  elicited and recorded with the application of
  assessment procedures, treatment procedures or in
  response to functional activities and positions.
• Mechanical responses
• The measurable changes that occur in movement
  loss, dural tension, neurological function,
  tolerance to functional activities and positions,
  or change in tested physical abilities.

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Examination terms

• Terms used to determine the response to repeated
  movements, sustained positions, treatment
  procedures and/or functional activities and
  positions on pain patterns in musculoskeletal
  disorders.
• These are used BEFORE, DURING and AFTER the
  procedure to accurately evaluate the response.

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During Mechanical Loading
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After Mechanical Loading
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EVALUATION PROCESS

• PATIENT HISTORY 1 role is to establish a
  hypothetical diagnosis
• Location of pain
• Duration of current episode of pain
• Intermittent or Constant pain
• MOI
• Symptomatic and Mechanical responses to
• bending, sitting, rising from sitting, turning,
  lying, rising form lying upon waking, as the day
  progresses, in the evening, when still and when
  on the move
• How many previous episodes and similarities?
• RED FLAGS and possible contraindications to MDT?
• Occupation

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PHYSICAL EXAMINATION

• Primary role is to confirm hypothetical diagnosis
  from patient history along w/ determining
  appropriate loading strategy
• Posture
• Habits
• Acute spinal deformity lateral shift,
  torticollis, etc
• Other abnormalities leg length difference,
  scoliosis, atrophy, etc

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Physical Exam - cont

• Neuro exam as appropriate
• Movement Loss
• Willingness to move/quality/quantity
• Baseline for determination of the mechanical
  response of the test movements/positions
• Repeated Movement
• Observations are made as to symptom and
  mechanical response after several repetitions
• Sustained test
• can be performed if the repeated test movements
  dont provide adequate information to come to a
  conclusion
• Other ie VBI, Hip, SIJ, Shoulder etc clearing
  tests

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Test Movements Cervicalaka Active
Physiological Movements

• Protrusion (Pro) and Repeated (Rep Pro)
• Retraction (Ret) and Repeated (Rep Ret)
• Retraction Extension (Ret Ext) and Repeated (Rep
  Ret Ext)
• Sidebend (SB) and Repeated (Rep SB)
• Rotation (Rot) and Repeated (Rep Rot)
• Flexion (Flex) and Repeated (Rep Flex)

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Protrusion
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Retraction
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Retraction Extension
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Flexion
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Sidebend
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Rotation
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Derangement Syndromes
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Derangement Syndromes
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Derangement Syndromes
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Derangement Syndromes
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Derangement Syndromes
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References

• Donelson R, Aprill C, Medcalf R, Grant W. A
  prospective study of centralization of lumbar and
  referred pain. A predictor of symptomatic discs
  and anular competence. Spine 22(10)1115-22,
  1997.
• Long A The centralization phenomenon its
  usefulness as a predictor of outcome in
  conservative treatment of chronic low back pain,
  a pilot study. Spine 20(23)2513-2521, 1995.
• Long A, Donelson R, Fung T Does it matter which
  exercise? A randomized control trial of exercises
  for low back pain. Spine Dec 129(23)2593-2602,
  2004.
• McKenzie Course notes A, B, C, D, E
• McKenzie RA 1990. The lumbar spine mechanical
  diagnosis and therapy. Spinal Publications, New
  Zealand.
• McKenzie RA 1990. The cervical and thoracic
  spine mechanical diagnosis and therapy. Spinal
  Publications, New Zealand
• McKenzieMDT.org
• Petty NJ 2006. Neuromusculoskeletal examination
  and assessment a handbook for therapist, 3rd ed.
  Elsevier Limited.
• Spitzer WO. Scientific approach to the assessment
  and management of activity-related spinal
  disorders A mono-graph for clinicians. Report of
  the Quebec Task Force on Spinal Disorders. Spine
  198712(7 Suppl)1-59.